This effectiveness trial assesses a set of asthma tools designed to provide primary care practices with simple, easily implemented methods to 1. Track and report current care and care improvements, 2. Monitor patient symptoms, trigger avoidance, level of adherence and 3. Guide care using a linked algorithm for management (not just drug therapy). The specific aims are to assess the impact of the tools compared to usual care to: 1. improve patient-oriented and practice process outcomes for asthma care;2. and maintain the improvements over 2 years. In addition, we will 3. Explore facilitators and barriers of implementing the Asthma APGAR tools within and across family medicine practices. The Asthma APGAR tools were developed and initially validated in rural primary care practices with R03 funding from AHRQ and a small grant from the AAFP Foundation. When implemented in rural family medicine practices the Asthma APGAR tools have been shown to change the content of asthma care, modify physician prescribing patterns and increase patient satisfaction with asthma care. This study takes the next step of assessing the ability of the tools to improve patient outcomes and practice efficiency. The Asthma APGAR tools address five domains critical to the tracking, assessment, monitoring and management of asthma.(See Table 1) The tools include a simple practice asthma care audit to motivate, monitor and report asthma care change;a patient-completed survey to be used at all asthma visits to monitor control and address the most common reasons for lack of control and finally a care algorithm that is based on the 2007 national asthma guideline's STEP therapy but incorporates non-drug management items such as asthma education, asthma action plans and inhaler technique evaluation. This clinical trial will focus on smaller practices and incorporates a simplified change process to implement, and sustain systematic use of the Asthma APGAR tools within these smaller, rural practices that should lead to more guideline adherent asthma care and improved patient outcomes. In addition to assessing the traditional quantitative outcomes of a clinical trial, we will use qualitative methods to explore the factors that are associated with the ability and feasibility of implementing the Asthma APGAR tools and facilitate practice change within and across practices. The project uses an innovative set of tools and an innovative approach to practice change that embeds guided self-motivation as the first step in practice change. Table 1- APGAR domains A---Activity limitation P---Persistence of symptoms Day and night G---TriGger identification A---Adherence to medications R---Response to therapy PUBLIC HEALTH RELEVANCE: Asthma causes a great deal of illness and suffering among children and adults in the United States. Much of this suffering might be prevented if asthma care more closely followed the national asthma guidelines. Preliminary work suggests that even when physicians are familiar with national asthma guidelines, they do not have the tools to integrate the guidelines into everyday practice. This project assesses the impact of introducing a system of asthma care and tools called the Asthma APGAR into rural primary care practices. The Asthma APGAR helps practices identify gaps in their current care and provides tools to improve that care including a patient Asthma APGAR questionnaire to help define asthma control and explore the reasons for lack of control. The most common reasons for poor control are not knowing what triggers asthma symptoms or not being able to avoid triggers, inability to take asthma medication as prescribed, poor inhaler technique and lack of belief in current asthma management. The answers to the patient Asthma APGAR survey are directly linked to an asthma care algorithm that recommends next steps for asthma exacerbations, inadequately controlled asthma and well controlled asthma. The algorithm guides the clinician and staff through adherence evaluation, inhaler technique review, asthma education, trigger avoidance, use of an Asthma APGAR Action Plan and appropriate follow-up and planned asthma care visits. This study will compare patient asthma outcomes for patients cared for in practices using the Asthma APGAR system and those cared for in practices with usual care. Information on barriers to integrating the Asthma APGAR system into everyday primary care and patient satisfaction with the care using the Asthma APGAR will also be collected and analyzed. Developing a simple to use and implement system that improves asthma outcomes in primary care practices could have a major impact on the asthma burden for Americans.